Role of the Rehab Nurse in Care Transition

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Introduction   

Since the advent of Managed Care in the late 1980s and 1990s, the Centers for Medicare and Medicaid Services (CMS) has changed the world of healthcare by regulating reimbursement amounts to all healthcare providers. This payment model is based on evaluating and managing clients, time spent with the client, the quality of care, and client outcomes. (1) These changes in reimbursement have eliminated the fee-for-service payments to capped reimbursement (capitation). 

Capitation and newer payment systems are the models in which each facility or physician receives a budget based on how many clients are in their panel, their acuity, the quality of their services, and client outcomes. These changes have all affected us because of the HIPPA privacy act, patient surveys, etc. It began with physician practice and moved on to facilities initially for specific diagnoses such as CHF, COPD, and other chronic conditions. They are reimbursed based on length of stay, quality of care, medical necessity, and patient outcomes.  

The Affordable Care Act (ACA) also allowed better access to care for those who cannot afford insurance or have lost their employer-subsidized healthcare. It also provides comprehensive health for those clients who are institutionalized or have disabilities that prevent them from performing their ADLs and IADLs. (7) 

Changes in Nursing Roles 

Due to the new payment and quality of care model, nurses have seen changes in how and where they are employed, allowing them to practice in newer and different roles. In fact, in years past, there were no subacute rehab services, as the client convalesced in the hospital and was discharged after completing rehab or becoming well enough to be discharged home. 

Before managed care, clients would be admitted to hospitals for minor surgery such as pilonidal cyst removal, and some would have four days of recovery in the hospital. Today, this is an outpatient procedure. Another example is a client undergoing a cesarean section and staying in the hospital for 7-10 days as the provider told this client the insurance company would pay. 

At that time, the primary care provider handled most of the client’s issues, and there were fewer specialists than today. Also, nursing homes were only for those who needed full-time care and could be in the hospital for weeks and months until a bed became available in the nursing facility. The most surprising was a hospital stay for those who “needed” a respite from their life. 

Some newer nursing roles include case and utilization management, quality management, discharge planning, acute and subacute rehab nursing, and many outpatient settings. We have also seen a rise in nursing education for advanced practice nurses (APRNs) to fill roles traditionally filled by primary care and specialty providers and at the doctorate level for research and education. Additionally, because providers were asked to see more clients within a given time limit, the need for APRNs working in primary care offices and specialties has become the norm.  

If you have been a nurse providing care to clients for over 20-30 years, you will have witnessed how much healthcare has transformed. With new technology and medical advances, healthcare costs rose so rapidly that the government and insurers realized that things must change to lower costs while improving healthcare. Enter managed care and capitation. Capitation was initiated to help lower costs, with more oversight and evidence-based guidelines, meaning that healthcare providers must alter their practices to adhere to the guidelines set by CMS. 

As the years go by, more and more of this new payment structure has been implemented and changed across the U.S. One of the essential purposes of this new way to practice was to streamline and provide the best care to clients and institute preventive care measures that allow the client to take on more responsibility for their health.  

With all these changes, healthcare providers need assistance in achieving their goals. Primary and specialty care practices have employed more nurses for client triage and follow-up. Hospitals have employed nurses for utilization review of services so that the facility can teach and educate physicians in utilizing correct billing codes and documentation. Nurses are developing and implementing care plans for discharge to the appropriate level of care (transitional care management), which provides a safe handoff of clients to the next facility or home. (2)   

CMS has also added defined protocols for transitional care, such as 24- 48-hour telephone follow-ups for clients to schedule post-facility appointments within 7 -10 days with their primary care providers and to discuss discharge instructions and education for all conditions (2). Another role for nursing is that of a Case Manager who also follows clients post-discharge to ensure the needed services are obtained, streamline issues, and refer clients to the most appropriate level of care. The primary care office should contact the discharge facility to receive patient notes and discharge information. With the inception of the electronic medical record, this streamlines information from one doctor or facility to the next. (2) This also encourages clients to take responsibility for their health. (2) 

Rehab Nurse Role 

Since the world’s population is aging and there is a rise in chronic non-communicable diseases, rehab services are needed more than ever. Interventions for older adults allow nurses to provide these services since they are usually the first staff member clients encounter. (3) 

In rehab, it was found that nurses had managerial and clinical roles. Rehab nurses work with therapy services in the rehab facility. (3) They also perform assessments, care planning, interventions, and rehab process management and coordination. (3)  Nurses in rehab can use all of their skills while working with physical and occupational therapists, physiatrists, psychiatrists, speech therapists, social workers, and nutritionists to provide complete care plans using client-centered therapy goals that assist the client in working towards maximum functioning. (3) 

Rehab nurses must thoroughly understand these services to provide client-centered transitions and goal-oriented care, which provides excellent outcomes. (3) 

When CMS and insurance companies became more involved in health care quality and costs, skilled nursing facilities such as acute and subacute rehab became necessary for ongoing therapy and assistance. Many “nursing homes” today include a sub-acute facility (SNF) unit where clients needing more recovery time and treatment can be transferred. 

Some areas rehab nurses use their skills in rehab settings are as follows:  

• Administration as a director of nursing and the facility 
• Responsible for daily operations and managing staff. 
• Clinical Nurse Leader or charge nurse 
• Oversees the sub-acute unit, manages, educates, and assesses staff. 
• Clinical Nurse Specialist: an APRN specializing in geriatric nursing, wound management, or specific diseases. 
• Consultant to staff, clients, families, and other facilities or agencies. 
• Staff rehab nurse performs all patient care, carries out medical and rehab plans, and delivers medications and treatments while conferring with all other rehab and nursing staff.  
• Case Managers work in all facilities and institutions to develop and ensure care plans are appropriate to the patient and carried out efficiently and effectively.   
• Nurse Practitioner: An APRN who is usually onsite to perform ongoing medical assessments and collaborate with physicians and other staff members in the SNF, including medication utilization and management. 
• Liaison nurse: Visits hospitals and other facilities to educate clients about the acute or subacute facilities they represent and works with hospital case managers or discharge planners to facilitate the client’s safe transfer to their facility or visiting nurse agency. 

Safety and advocacy are critical when a client is transferred to a rehab facility. Regarding teamwork in rehab, describing the competencies and roles of workers from different disciplines is essential. (8) Acute care staff must determine the client’s needs, and which facility will most appropriately care for each individual.  Some facilities do this on morning rounds. Again, the goal is for the client to achieve client-centered, cost-effective, quality care and excellent outcomes. (3)  

The rehab liaison nurse meets with the client and acute care case manager or social worker to determine if their facility will address all of the client’s needs. Some facilities specialize in different illnesses or injuries, so it is essential to make the appropriate determination. Other important items are how much therapy the patient can tolerate in hours, all acute care hospital documents, history and physical, diagnosis(es) and notes through the acute stay, medication reconciliation, physician or surgeon, family member or guardian, and code status. 

The liaison nurse and hospital case manager advocate for the client and communicate all information to the SNF. (3) Transfer to SNF care plans must be inclusive and highly complex to reduce readmissions to acute care before 30 days of SNF admission.  Once all is set, the patient should safely be transferred to the facility by ambulance. Rehab nurses should incorporate a holistic practice that includes all aspects of the client, i.e., cognition, dietary needs, physical status, and the ability to perform ADLs and IADLs. Elderly clients who have debilitated while in the acute facility may need more rehab than previously considered. (3) 

In the SNF, nurse leaders, primary nurses, therapists and case managers are responsible for determining whether the client is advancing with rehab, who the support systems are, and what the living conditions are. If there are financial or psychosocial issues, the case manager, nurse leader, and the client’s primary nurse collaborate with social workers to develop a plan. Patient advocacy is critical in all aspects of healthcare. The SNF may have meetings daily with the whole team to discuss the prognosis, progression, estimated length of stay, and evaluation of all clients, especially those who have just been transferred to their facility. 

Case Study 

A 55-year-old client was admitted to SNF from another state with many wounds and injuries after a severe car accident. The client was awake, alert, and oriented to all questions asked during the rehab case manager’s assessment. The case manager visited the client at admission to SNF and 2 days later to assess their therapy progression and answer any questions. At this time the client was upset because they felt they should be in an acute rehab facility, not SNF, as they were young and thought they could do more extensive rehab.  

The case manager conferred with the primary rehab nurse, the clinical leader, the therapists, and the administrator.  There was some discussion about the client remaining in the SNF; however, the client was very unhappy and insisted he wanted acute rehab. 

The SNF case manager called the client’s insurance company with all the case details and was told the client would be covered for acute rehab. The client and all staff involved were informed, and the client was eventually transferred to acute rehab. 

Considerations  

The older population can be lost when a plan is developed for safe transfer. This is especially true for seniors with more than one diagnosis and are clients of several providers. (4) It is imperative to ensure the client and family take part and understand the plan since some clients may have poor hearing or memory. 

Nurses must use their resources to gather the most information from the client, family, facilities, etc. while developing the transfer plan. The rehab plans should be highly complex as this promotes more satisfaction with the care and reduced hospital readmissions when the transition is completed smoothly. All questions and concerns of the client and family must be addressed. (4,5). It is also vital to provide emotional needs for the family and caregivers. (5)   

There have been gaps in transitional care with elderly clients, including incomplete transfer of information and education of the client and family regarding expectations and the type of available services. (4,5) That said, studies have shown that “nurse-led interdisciplinary interventions” show the highest quality of care and cost savings (5).  Again, incomplete information during transfers, even within the facility, from ED to ICU to a medical-surgical bed, has been associated with poor outcomes for clients, higher hospital readmissions, less client and family satisfaction, and unmet needs (5). 

Another vital aspect of an excellent transition of care is that nurses learn and understand the roles of the other nurses who develop and deliver care in the hospital, SNF, and home care. (6,8) This is especially important for stroke clients who may be transferred up to 7 times during their illness. (6) The client and family expect seamless care and transition. (6) Educational videos and pamphlets can be developed to help clients, and their families understand what to expect in transitioning care. (6)  

Another concern is that poor transfer management can produce inadequate control of co-morbidities, medication errors, the stress of the transfer, poor patient and caregiver knowledge of transition and preparation, and an increase in morbidity and death. (7) Some institutions employ hospitalist physicians to follow clients in the hospital and the SNF to gain a higher quality of care and patient satisfaction. (7)   

Conclusion

Client-centered healthcare has become the norm. Today, the system is charged with better outcomes for clients, lowering costs and ensuring the client receives the appropriate care.  This is even more critical for the elderly and those with chronic conditions. (10) Clients who experienced appropriate transitions from one level of care to another showed even more improvement within the 6 months after admission. (10) The most important thing is communication between providers and facilities. Without this vital part of the transfer, client quality of care and satisfaction may be lower, with increasing costs and readmissions. (10) 

Some assistance with communication is electronic medical records (EMRs), which all facilities in the area can use and view. Other facilities can see these records if the client allows.  There are also universal transfer forms that can be used to exchange information.  Another critical element is medication reconciliation by all agencies so that medications discontinued or changed are not on any transfer form and are noted on the EMR. (9) 

A smooth transition from rehab to home is essential for the client, as this can be when they are most vulnerable. Therapy and rehab nurses should visit the client’s home to assess safety and other medical equipment and needs. (9) 

We have examined nursing’s new roles, particularly those nurses working in rehab settings.  As we have learned some of these roles, we have identified the importance of smooth transitions and the extent to which all nurses manage transitional care.  

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